Below is a list of diseases that may seem unrelated to the ...
Below is a list of diseases that may seem unrelated to the purpose of your appointment. However, these questions must be answered carefully as these problems can affect your overall course of chiropractic care.
CHECK ANY OF THE FOLLOWING DISEASES YOU HAVE HAD:
□ Pneumonia
□ Rheumatic Fever
□ Polio
□ Tuberculosis
□ Whooping Cough
□ Anemia
□ Measles
□ Mumps
□ Smallpox
□ Chicken Pox
□ Diabetes
□ Cancer
□ Heart Disease
□ Thyroid
□ Influenza
□ Pleurisy
□ Arthritis
□ Epilepsy
□ Mental Disorders
□ Lumbago
□ Eczema
INTAKE
□ Coffee
□ Tea
□ Alcohol
□ Cigarettes
□ White Sugar
CHECK ANY OF THE FOLLOWING DISEASES YOU HAVE HAD IN THE PAST SIX MONTHS:
MUSCULOSKELETAL CODE
□ Low Back Pain
□ Pain Between Shoulders
□ Neck Pain
□ Arm Pain
□ Joint Pain/Stiffness
□ Walking Problems
□ Difficulty Chewing/Clicking Jaw
□ General Stiffness
NERVOUS SYSTEM CODE
□ Nervous
□ Numbness
□ Paralysis
□ Dizziness
□ Forgetfulness
□ Confusion/Depression
□ Fainting
□ Convulsions
□ Cold/Tingling Extremities
□ Stress
GENERAL CODE
□ Fatigue
□ Allergies
□ Loss of Sleep
□ Fever
□ Headaches
GASTROINTESTINAL CODE
□ Poor/Excessive Appetite
□ Excessive Thirst
□ Frequent Nausea
□ Vomiting
□ Diarrhea
□ Constipation
□ Hemorrhoids
□ Liver Problems
□ Gall Bladder Problems
□ Weight Trouble
□ Abdominal Cramps
□ Gas/Bloating After Meals
□ Heartburn
□ Black/Bloody Stool
□ Colitis
GENITO-URINARY CODE
□ Bladder Trouble
□ Painful/Excessive Urination
□ Discolored Urine
C-V-R CODE
□ Chest Pain
□ Short Breath
□ Blood Pressure Program
□ Irregular Heartbeat
□ Heart Program
□ Lung Program/Congestion
□ Varicose Veins
□ Ankle Swelling
□ Stroke
EENT CODE
□ Vision Programs
□ Dental Programs
□ Sore Throat
□ Earaches
□ Hearing Difficulty
□ Stuffed Nose
FEMALES ONLY:
Date of last period:
____________________
Are you pregnant?
□ Yes □ No
MALE/FEMALE CODE
□ Menstrual Irregularity
□ Intense Menstrual Cramps
□ Vaginal Pain/Infection
□ Breast Pain/Lumps
□ Prostate Sexual Dysfunction
□ Other Problems:
FAMILY HISTORY
The following members have the same or similar problem(s) as I do:
□ Mother
□ Father
□ Brother
□ Sister
□ Spouse
□ Child
Corinth Chiropractic, P.A. ● 4851 I-35 E, suite 202 ● Corinth, TX 76210
Dear Patient:
Please be aware that the purpose of this examination is to determine your level of impairment. Impairment is defined as the loss of, loss of use of, or derangement of any part, system, or function. Disability is the limiting loss or absence of the capacity of an individual to meet personal, social, or occupational demands, or to meet statutory or regulatory requirements.
Please read the following directions and complete the impairment checklist. In terms of a normal day where you are active 16 hours and sleep 8 hours, “occasionally” means up to 33% of the day, “frequently” means 34% to 66% of the day, “continuously” means 67% to 100% of the day. Please mark how the specific injury(ies) you are being examined for now impair your life in a normal day.
ACTIVITIES OF DAILY LIVING IMPAIRED
Not at All Occasionally Frequently Continuously
Self care & personal hygiene ( ) ( ) ( ) ( )
Normal living postures
(sitting, lying down, etc.) ( ) ( ) ( ) ( )
Travel ( ) ( ) ( ) ( )
Sexual function ( ) ( ) ( ) ( )
Social & recreational activities ( ) ( ) ( ) ( )
Communication ( ) ( ) ( ) ( )
Ambulation (moving around) ( ) ( ) ( ) ( )
Non-specialized hand activities ( ) ( ) ( ) ( )
Sleep ( ) ( ) ( ) ( )
Writing ( ) ( ) ( ) ( )
Other ( ) ( ) ( ) ( )
Other ( ) ( ) ( ) ( )
Signature Date
Corinth Chiropractic, P.A. ● 4851 I-35 E, suite 202 ● Corinth, TX 76210
Please circle on this line the level or intensity of pain that you are presently experiencing.
Absolutely Worse pain
Pain Free 1 2 3 4 5 6 7 8 9 10 Imaginable
Mark the areas on your body where you feel the described sensations with the appropriate symbols below. Mark the areas of radiation. Please include all affected areas.
Numbness Dull Ache Hot Burning Sharp/Stabbing Pins& Needles
= = = 0 0 0 X X X / / / + + +
(Describe any other discomfort/sensation____________________________, and use * * * on the affected areas)
Signed:
Date:
Corinth Chiropractic, P.A. ● 4851 I-35 E, suite 202 ● Corinth, TX 76210
NEW PATIENT INFORMATION
Welcome to Corinth Chiropractic! Please complete all questions.
|Name: Date: |
|Address: City/state/zip: |
|Home Phone: Work: |
|Birth date: Age: Social Sec. #: |
|Marital Status: Email: |
|Your Employer: Occupation: |
|Spouse’s Name: Spouse’s Employer: |
|Children’s Names & Ages: |
|Favorite Hobbies & Interests |
|Method of Payment for First Visit: Cash Check Credit Card |
Current Health complaints/reasons for consulting our office:
1.__________________________________________________________________________
2.___________________________________________________________________________
3._____________________________________________________________________________
4._______________________________________________________________________________
Who may we thank for referring you?______________________________________________________
Have you had same or similar problems before?______________________________________________
If so, for how long?_____________________________________________________________________
Is this the result of an auto or work injury? If so, when?___________________________
Immediate family with similar problems? If so, who?__________________________
Other doctors you have seen for this problem:___________________________________________
Surgeries you have had:____________________________________________________________
Medications you currently take:________________________________________________________
Is there any chance you are pregnant:_______________________________________________________
Have you ever been diagnosed with cancer: If so, what kind?______________________________
Do you have health insurance? Carrier/policy #
Corinth Chiropractic, P.A. ● 4851 I-35 E, suite 202 ● Corinth, TX 76210
-----------------------
ACTIVITIES OF DAILY LIVING IMPAIRMENT
PATIENT PAIN FORM
[pic]
Please indicate when you get the most pain. Check one only.
Sitting □
Standing □
Lying down □
Other □
_______________
The above information is true and accurate to the best of my knowledge.
Patient or Guardian Signature: Date:
................
................
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